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Introduction
Crazy for Loving You?: The Psychotherapy of
Verbal Abuse in Relationships
by Anne C. Fisher, PhD ADTR

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Definition: Verbal abuse is the mistreatment of others involving the expression of aggression through vocalization. Both those at whom these vocalizations are directed and those who experience them vicariously may be considered victims of verbal abuse. It is likely that the adult who is verbally abusive as well as the adult who is the recipient of verbal abuse was abused as a child. Verbal abuse may be combined with physical abuse and may take a variety of forms on a continuum from mild, such as subtle teasing, veiled criticism or sarcasm through severe, such as vocal expressions of uncontrolled rage. It is important to note that the definition of verbal abuse will vary with the cultural context and community environment in which the behaviors occur.

Clinical Example: Although 42 at the time he began in psychotherapy treatment with me, Charles was still the frightened boy in the childhood pictures he brought to show me. He is a small man who had muscular tension so great that he looked as though he could shatter. His facial expression was fixed and emotionless. To look into his eyes was to see fear.

From an early age, Charles learned to remain in a disassociated state to cope with his constantly angry, verbally abusive father and clinging, controlling mother. Unable to develop independently and authentically, instead, he developed a keeness of mind to stay one step ahead of the unpredictability at home and to shape himself around expectations he estimated his parents and others had of him. From an early age, Charles used intellect and achievement as coping, which led to academic success and later to professional success as a respected attorney. Although successful, Charles had been plagued since childhood with sleep difficulties, anxiety, depression, disabling headaches and outbursts of rage.

Charles’ accommodating style made him a favorite of adults growing up, and he reports that throughout his life many have considered him a great co-worker and a good friend. Unfortunately, at the same time, he viewed himself as “a monster child;” unlovable, ugly and evil. Charles has been married twice, to volatile and aggressive women to whom he tended to cling, although they experienced him as passive, remote and emotionally unavailable. He initially came to treatment as his first marriage was ending.

Although Charles’ history is rather dramatic, his treatment has been quite successful. He no longer becomes depressed, he rarely has headaches, sleep difficulties or emotional outbursts. His anxiety is greatly decreased, and Charles now knows himself, values himself and has more trust in the world, all of which support him in expressing himself and in making deeper relationships. Now in the later stages of individual psychotherapy, and with his second wife also in individual treatment, we are beginning to talk about beginning couples work.

The Psychotherapy of Verbal Abuse in Relationships: Over the years, I have found that the treatment of verbal abuse is most effective in the controlled relational environment interactions among several major aspects of functioning. These aspects include personality development, psychological defenses, emotional regulation, cognitive style regarding the self, others and life, and communication skills. Toward the later stages of individual treatment, couples therapy or family therapy can provide opportunities to explore current relationships in the care and safety of the therapeutic relationship.

The positive therapeutic relationship is the foundation of the treatment of abuse and is discussed below. It is followed by specific areas of focus for individual psychotherapy, beginning with a case example for each section, and followed by description and suggestions for intervention.

The Therapeutic Relationship

Therapist Presence: “When I began working with you, it was like I had kept myself in a box my whole life. I was finally able to do what I had never been able to do before -- open myself and trust.” Timothy said this to me during a session, as he reflected upon how different he now feels within himself and in his relationships. A therapist can be a gifted theoretician and technician, but there is nothing more crucial to successful psychotherapy than the therapeutic relationships we make with our patients. This is of particular importance when psychological difficulties form as a result of relational damage. In an atmosphere of acceptance, respect and kindness, self-exploration and healing regarding relationship can occur. It is the relationship with us that our patients will use as a new model for current and future relationships.

Cautions for the Therapist: “I can’t believe how much I hate you sometimes,” William often yells at me during our sessions. The therapy with verbal abusers or their victims can be challenging and may hold potential hazards for the therapist. Perhaps the greatest pitfalls include feeling hurt by or angry at our patients and reacting aggressively toward them. Although the reactions we have as therapists inform us about how are patients are feeling or have been treated, as well as guide us in formulating interventions, it can be difficult to contain our reactions when working with issues of verbal abuse. This may be a particular vulnerability for those of us who have experiences with abuse in our personal histories.

Specific Areas of Attention in the Treatment of Verbal Abuse

Personality Development. Nina was exasperated as she sobbed to me, “I was so angry at him for staying out all night with his friends. I yelled at him until I lost my voice. At one point, I said, ‘I’m addicted to you like a drug. I just can’t take it anymore, but I don’t know how to stop.’” Abuse halts the natural momentum toward psychological development. Patients may be left without a basic sense of safety, or struggling to meet dependency and/or personal power needs. Personality disorders may result. Of course, living in these developmental stages have profound effects on the quality of relationships, putting a person at risk to become abusive or to become a victim of abuse.

Interventions:

1. Assessing your patient’s personality development and using your assessment to create developmentally appropriate interactions to provide a “second chance” for normal development.

2. Looking with your patient at the patient’s developmental functioning and exploring the effects of developmental strengths and limitations on current relationships, using emerging situations within or outside the therapy for learning.

Psychological Defenses. Powerful, primitive defenses develop automatically and unconsciously to cope with abusive treatment. A basic sense of safety may be damaged, leaving a person in a constantly anxious state of emergency. Self-awareness is impaired by defenses that create a disassociation from self. Suppression of emotion and physiological functioning may result in depression. Of course, feelings of threat and lack of awareness of self can set the stage for abusive behavior or becoming a victim of abuse.

Interventions:

1. Observing defensive states as they are reported or as they emerge in the sessions, and exploring their functions.

2. Guiding your patient toward non-emergency states and increased self-awareness. Imagery, breathing awareness, relaxation and body movement are excellent interventions for this. Simultaneous observations and interpretation of defenses as they emerge is key to moving defenses.

Emotional Regulation. “I can’t believe how angry I was at her. Before I knew it, I was screaming at her and pounding my fists on the floor. It’s just not me to act like that. I really scared her,” Janet confessed to me regarding her reaction to her daughter. Although affected by individual constitution, emotional regulation forms from the outside in, as adults help children to learn to manage strong emotions and aggression. Powerful learning also occurs vicariously through the observations of the emotional regulation of others. Without positive opportunities for learning, lack of self-control, for example of one’s vocalizations can result in abusive behavior.

Interventions:

1. Helping your patients to become aware of difficulties in self-regulation through situations that emerge within and outside your sessions.

2. Teaching your patient techniques for self-regulation, such as distinguishing between inner states and behavior, practicing silence, walking away from an upset, quieting strong feelings and reactions through relaxation and channeling strong emotions to positive activity.

Cognitive Style. Jimmy justified an experience of rage that occurred while shopping recently at a department store. “People just don’t care. The clerk’s actions were saying to me, ‘you are nothing.’ I sure put her in her place.” Patients who have been mistreated are likely to have a poor self-esteem, a negative view of relationships, and a pessimistic view of life. They are likely to create situations in which they continue to be mistreated, or they take the role of the aggressor and mistreat others.

Interventions:

1. Helping your patient to notice and to record in detail thoughts about the self, others, and life, and teaching your patient to interrupt, through self-talk, erroneous or excessively negative thoughts.

2. Collaborating with your patient to create new, more balanced ways of thinking about the self, others, and life.

3. Encouraging the practice of these new patterns through positive self-talk.

Communication Skills. “You need a new suit, your hair looks terrible, and you have bad breath.” This was the greeting Maya gave to her husband when he entered my office to join her for a recent couples therapy session. We learn communication through how others communicate with us. Frequently, I have directed at me, in individual work or overhear in a couple, ways of communicating that are sure to create relationship difficulties. Note that sometimes the words aren’t so much the issue as the way something is said, such as in the voice tone, or nonverbal accompaniments to what is said.

Interventions:

1. Supporting awareness of communication by observing and reflecting content to your patient, as well as non-language aspects of communication.

2. Modeling for your patient polite, respectful communication, and encouraging your patient to practice it with you in the sessions and with others outside the sessions.

Final Thoughts: Working with verbal abusers and victims of verbal abuse can be challenging. The combination of primitive defenses, early personality development, difficulty with emotional regulation, negativity and pessimism in thought, and poor communication skills can leave a therapist feeling pained and frustrated. Hence, it is crucial that, in the process of caring for our patients, that we also remember to do the things for ourselves that support our own well-being.

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